Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 159; no. 6; pp. 2230 - 2240.e15
• Main Authors: Michler, Robert E., Ailawadi, Gorav, Perrault, Louis P., Miller, Marissa A., O'Sullivan, Karen, Hung, Judy W., Overbey, Jessica R., Iraola, Margaret, Gelijns, Annetine C., Moskowitz, Alan J., Taddei-Peters, Wendy C., Geller, Nancy L., Lee, Albert, Ascheim, Deborah D., Bagiella, Emilia, Moquete, Ellen, Chang, Helena, Chen, Yingchun, Goldfarb, Seth, Gupta, Lopa, Santos, Milerva, Weglinski, Michael, Williams, Paula, Wiggers, Henrik, Adame, Tracine, Ryan, William, Grayburn, Paul, Chen, Frederick Y., Aranki, Sary, Davidson, Michael, Prieto, Ignacio, Dionne, Joannie, Lackner, Pamela, Berroteran, Leoma, Smith, Craig R., Naka, Yoshifumi, Stewart, Allan, Van Patten, Danielle, Alexander, John H., Mathew, Joseph P., Parsa, Cyrus J., Tong, Betty C., Ferguson, T. Bruce, Akers, Brenda, Puskas, John D., Baio, Kim, Speir, Alan M., Magee, Patrick, Keyte, Sally, Dang, Minh, Slaughter, Mark, Headlee, Marsha, Moody, Heather, Birks, Emma, Shepard, Stephanie A., Nanney, Tracy, Hampton, Lynne C., DeRose, Joseph J., Taub, Cynthia, Basmadjian, Arsène-Joseph, Bouchard, Denis, Carrier, Michel, Tanguay, Jean François, El-Hamamsy, Ismail, Robichaud, Sophie, Corcoran, Philip C., Hasan, Ayseha, McDavid, Asia, Peterson, Mark D., Cohen, Gideon, Moussa, Fuad, Christakis, George, David, Tirone, Garrard, Lisa, Meyer, Steven, Kuurstra, Emily, Dent, John M., Kern, John, Dixon, Dennis O., Haigney, Mark, Holubkov, Richard, Jacobs, Alice, Murkin, John M., Spertus, John, McDonald, Cheryl L., Williams, David O., Richenbacher, Wayne, Rao, Vivek, Miller, Rachel, Pinney, Sean, Roberts, William C., Walsh, Mary N., Keteyian, Stephen J., Aldred, Heather, Browndyke, Jeffrey
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-06-2020
• Subjects: Aged; CABG; Canada; Cardiothoracic Surgical Trials Network; Computer Simulation; Coronary Artery Bypass - adverse effects; Coronary Artery Bypass - economics; Coronary Artery Disease - complications; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - economics; Coronary Artery Disease - surgery; Cost-Benefit Analysis; cost-effectiveness analysis; Female; health care costs; Heart Valve Prosthesis Implantation - adverse effects; Heart Valve Prosthesis Implantation - economics; Hospital Costs; Humans; ischemic mitral regurgitation; Male; Middle Aged; mitral valve; Mitral Valve Annuloplasty - adverse effects; Mitral Valve Annuloplasty - economics; Mitral Valve Insufficiency - diagnostic imaging; Mitral Valve Insufficiency - economics; Mitral Valve Insufficiency - etiology; Mitral Valve Insufficiency - surgery; mitral valve repair; Models, Economic; Multicenter Studies as Topic; Quality of Life; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Risk Factors; Time Factors; Treatment Outcome; Canada; quality-adjusted life years; ICER; MR; mitral valve repair; LVESVI; MV; HR; cost-effectiveness analysis; Cardiothoracic Surgical Trials Network; health care costs; CTSN; UI; ischemic mitral regurgitation; QALY; mitral valve; ICU; SF-6D; CABG; CEA
• ISSN: 0022-5223; 1097-685X; 1097-685X
• DOI: 10.1016/j.jtcvs.2019.06.040

The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival.
We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty.
In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year.
The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.